Normal & Abnormal Uterine Bleeding

1. Normal & Abnormal Uterine Bleeding Suzanne Bush, MD, FACOG Clinical Associate Professor FSU College of Medicine

2. Objectives • Recognize the characteristics of Normal Menstrual Bleeding (The LMP as the fourth vital sign!) • Describe the etiologies of Abnormal Uterine Bleeding (AUB.) • Understand etiologies of AUB with respect to the life stages of women. • Understand the diagnostic tools to identify the etiology of the AUB. • State the medical & surgical options available in primary care and gynecology settings.

3. Case One • 22 year old G0P0 presents for well woman care. She is concerned about her periods being irregular. She describes her cycles as coming the 18th of one month & the 16th the next month. She never knows when it is coming. • How would you counsel this patient?

4. Normal Menstruation • The Menstrual Cycle In the normal menstrual cycle, orderly cyclic hormone production and parallel proliferation of the uterine lining prepare for implantation of the embryo. Berek & Novak’s Gynecology, 2012, p.145

5. Normal Menstruation • “The menstrual cycle starts with the first day of bleeding of one period and ends with the first day of the next. In most women, the cycle last about 28 days. Cycles that are shorter or longer by 7 days are normal.” ACOG Website: FAQ095

6. The Normal Menstrual Period • Blood loss < 80 ml (average 30-35 ml) • Duration of flow 2-7 days (average 4 days) • Cycle length 21 - 35 days (average 29 days) (28 days +/- 7 days}

7. Phases of the Menstrual CycleReproductive Cycle • Follicular • Begins with Menses ends with luteinizing (LH) hormone surge • Ovulation (30-36 hours) • Begins with LH surge and ends with ovulation • Luteal (14 days) • Begins with the end of the LH surge and ends with onset of menses

8. The Normal Menstrual CycleAnother Way of looking at it M. Manting; DUB LECTURE 2008

9. Phases of the Menstrual CycleEndometrium • Proliferative • Begins with menses and ends at ovulation • Secretory • Begins at ovulation and ends with menses

10. The Normal Menstrual CycleAnother Way of looking at it M. Manting; DUB LECTURE 2008

11. Regulation:Hypothalamic Pituitary Axis • Hypothalamus is the pulse generator mediated through GnRH • GnRH cannot be directly measured • Negative Feedback

12. Regulation of The Ovary2 Cell Theory • Theca Cell • Granulosa Cell

13. Case One • 22 year old G0P0 presents for well woman care. She is concerned about her periods being irregular. She describes her cycles as coming the 18th of one month & the 16th the next month. She never knows when it is coming. • How would you counsel this patient?

14. How would you counsel this patient?

15. Abnormal Uterine Bleeding (AUB) • Definition: • Any change in menstrual period • Flow • Duration • Frequency • Bleeding between cycles • Prevalence: • 20 million office visits/year • 25% of visits to gynecologists

16. Old Terminology • Menorrhagia • Metrorrhagia • Menometrorrhagia • Polymenorrhea • Dysmenorrhea • Amenorrhea • Oligomenorrhea • Hypomenorrhea

17. New Terminology • Heavy Menstrual Bleeding • Acute • Chronic • Intermenstrual Bleeding

18. HPI Onset Quantity : Spotting or heavy daily or intermittent Duration History for AUB

19. History for AUB • Associated Symptoms • Pain • Dysmenorrhea • Menstrual Changes • Timing • Flow (clots) • Frequency • Fever/chills • Changes in hair/ body • Bruising/bleeding • Rectal/urethral bleeding • Nausea/vomiting

20. Gender Specific History • Menstrual • Contraception • Gynecologic • Obstetric • Sexual • Genital Infections

21. Other Important Details • Family History • Anyone else? • Von Willebrand's • PCOS • PSH • Nutrition and exercise • Weight changes • Exercise habits • diet • PMH • Chronic conditions • Liver disease • Kidney disease • Anemia • Drugs /medications • Psychiatric medications • Thyroid Disorders • Blood thinners

22. Case Two • 48 year old G2P2, S/P Bilateral Tubal Ligation 14 years ago, presents to your office with RLQ pain of 3 months duration. LMP 5 weeks ago has had many years of irregular menses thought to be PCOS. • Ultrasound shows an 8 cm adnexal cyst with CA 125 normal.

23. Differential Diagnosis Of AUB • Structural: PALM-COEIN (Non Gravid Women) • Life Cycles: Pre-menarche Menarche Reproductive Post-Menopause • Anatomic:“Bottoms Up”

24. P Pregnancy Never Forget Pregnancy Age is Not An Issue! PROVE IT! Assumptions can lead to death

25. PALM-COEIN • FIGO Classification System (PALM-COEIN) for causes of AUB in non gravid women of reproductive age • Structural vs. Non-Structural • Developed to create a universally accepted nomenclature

26. PALMStructural Causes P- Polyp (AUB-P)A- Adenomyosis (AUB-A)L- Leiomyoma (AUB-L) Submucosal myoma (AUB-LSM) Other myoma (AUB-LO)M- Malignancy & hyperplasia (AUB-M)

27. COEINNon-Structural Causes C- Coagulopathy (AUB-C)O-Ovulatory dysfunction (AUB-O)E- Endometrial (AUB-E)I- Iatrogenic (AUB-I)N- Not yet classified (AUB-N

28. AUB-O • Abnormal Uterine Bleeding with ovulatory dysfunction • Heavy, irregular bleeding

29. Causes of Anovulation: Physiologic • Adolescence • Menopause Transition • Lactation • Pregnancy

30. Causes of AnovulationPathologic • Hyperandrogenic anovulation (e.g., PCOS, CAH, or androgen-producing tumors) • Hypothalamic dysfunction • Hyperprolactinemia • Thyroid disease • Pituitary disease • Premature ovarian failure • Iatrogenic (Chemo) • Medications

31. Case #2 • 28 yo nulliparous female presents with history of heavy menstrual bleeding. On further questioning she states that she has always bled heavy and irregularly since menarche @ age 12. She is always anemic & tired. • Her physical exam is noted for a BMI of 47. There is no hirsutism, acne or skin changes.

32. Case # 3 • 42 year old G3P3 who goes is in your civic group presents with heavy, cyclic uterine bleeding. You note spider angioma across her chest & down her arms. She has a slightly protuberant abdomen. Her husband had a vasectomy 7 years ago.

33. The next step in evaluating her heavy uterine bleeding:

34. Liver Disease • Patients known to have liver disease manifest additional symptomatology because of abnormal hepatic function. • Evaluate patients for spider angioma, palmar erythema, splenomegaly, ascites, jaundice, and asterixis.

35. C Coagulation Disorders Rule out von Willebrand's in any girl who requires transfusion for excessive bleeding when first starting periods

36. O Bleeding from ther Sites • GI • Neoplasia or hemorrhoids • GU • Urethral caruncle or diverticulum • Renal lithiasis or hemorrhagic cystitis • GYN • Labia, cervix, or vagina • Trauma, infection, or neoplasia Remember Hemoccult & Urinalysis

37. Differential Diagnosisof AUB: Life Cycles • Pre-Menarche • Menarche • Reproductive • Postmenopausal

38. Etiology of AUB Life Cycles Approach • E2 withdrawal @birth • Foreign Body • Sarcoma • Ovarian Tumor • Trauma • Coagulation Defects • Hypothalamic Immaturity • Psychogenic • Pregnancy • Anovulation • Endogenous • Exogenous • Anatomic • Carcinoma • Vaginal Atrophy • E2 Replacement • Anatomic Post-Menopausal Menarche Reproductive Premenarchal

39. Differential Diagnosis of AUB: Structural • “Bottoms Up” • Vulva • Vagina • Cervix • Ovary • Brain • Contiguous Anatomy • GU • GI • Non-Pelvic Etiology • Endogenous • Iatrogenic

40. Vulvar • Infections • HPV • Atrophy • Benign Lesions • Cancerous lesions • Dermatologic Causes PHYSICAL EXAM: INSPECTION IS IMPORTANT

41. Vagina • Malignancy : • Carcinoma • Sarcoma • Infections • Foreign bodies • Diaphragm, Pessary • Tampon • other • Laceration/trauma • Atrophic changes • Granulomatous tissue • formed after surgery • post hysterectomy Physical Exam: Inspection is important

42. Cervix • Neoplasia • Cancer • Polyps • Myomas • Cervical Eversion (Ectropion) • Infection • Cervicitis • Condyloma Acuminata IMPORTANT: Visualize the Cervix!

43. Postmenopausal Bleeding is considered endometrial cancer until proven otherwise Uterus • Myomas • Polyps • Endometrial Hyperplasia • Endometrial Carcinoma • Atrophy Postmenopausal bleeding is evaluated by an Endometrial biopsy Most PMB Is due to Atrophy PHYSICAL EXAM: Bimanual Exam checks enlargement

44. Ovary • Anovulation • PCOS • Menopause Transition

45. PathophysiologyEtiologies Of AUB • Estrogen Withdrawal • Estrogen Breakthrough • Progesterone Withdrawal Clinical Management of Abnormal Uterine Bleeding: APGO Educational Series, May 2002, p. 8.

46. Initial Assessment of AUB • Acute • Sub-Acute • Chronic

47. Initial Assessment of AUB • History & Physical • Vital Signs • Shock Signs • Laboratory • Pregnancy Test • Complete Blood Count

48. EVALUATION OF AUB YES NO

49. Evaluation of AUB • Evaluation of the Endometrium • Pregnancy test • Endometrial Biopsy • Transvaginal &/or abdominal Ultrasound (TVS/AUS) • Saline Sono-hysterocopy (SIS) • Hysteroscopy • Evaluation of the Uterus • TVS • SIS • Hysteroscopy

50. Endometrial Biopsy (EMB) • Evaluation of the Endometrium • Pipelle